The frequency and effects of distractions in operating theatres.

BACKGROUND: Operating theatres (OTs) are complex environments where team members complete difficult tasks under stress. Distractions in these environments can lead to errors that compromise patient safety. A range of potential distractions exist in OTs and previous research suggests they are common. This study assesses the nature, frequency and impact of distracting events in the OT at a tertiary New Zealand hospital. METHODS: Prospective observational study of the frequency, type and impact of OT distractions during a 3-month period. Two observational methods - the frequency of door openings and a validated tool - were used to categorize OT distractions for a range of acute and elective, paediatric and adult surgical procedures according to their cause and effect. RESULTS: There were 57 procedures (2037 intraoperative minutes) observed. During this time, 721 door openings and 1152 other distracting events were recorded. On average, either a door opening or other distracting event was recorded 56 times per hour of intraoperative time. The frequency of distractions did not vary in relation to acute versus elective or paediatric versus adult procedures but were more common in the morning. Communication unrelated to the case was the most common distracting event: these and equipment issues had the greatest effect on the entire surgical team, usually by causing some interruption to operative flow. CONCLUSION: Distractions in OTs were common, occurring nearly every minute. Most were trivial, but some had the potential to disrupt the operative procedure and result in patient harm. Reducing distractions in surgery could reduce patient harm and improve resource use.

Treatment of gastric adenocarcinoma at a New Zealand centre: meeting the challenges of a low volume country.

BACKGROUND: Surgical treatment of gastric cancer in New Zealand is challenging because of a low annual incidence of 400 patients and population dispersal over a wide area with little data on regional treatment trends and outcomes. This investigation was undertaken to evaluate the surgical outcomes of gastric cancer patients presenting to a single upper gastrointestinal centre (WDHB, Waitemata District Health Board) and to compare these to national and international standards. METHODS: Data on 135 patients with histologically proven gastric adenocarcinoma presenting between January 2010 and December 2014 were reviewed and compared with nationally available procedural volume data. RESULTS: Sixty of 135 patients were resected (resection rate 44%) and 75 patients were managed with palliative chemotherapy/symptomatic care alone. Twenty-six patients (43%) received adjuvant or neoadjuvant chemotherapy and only two patients (3%) underwent laparoscopic resection. In resected patients, 90-day mortality was 1.6%, and 11 patients (18%) developed complications ≥ Clavien-Dindo grade 3. Fifty-two patients (87%) had ≥15 lymph nodes resected and 54 patients (90%) had a histological R0 resection. At median follow-up of 49 months, 30 patients remain alive and disease-free with 20 true 5-year disease-free survivors. National data between 2010 and 2014 showed WDHB performed 20% (338/1710) of gastric resections for all indications in New Zealand. CONCLUSION: While WDHB is an internationally low volume centre for gastric cancer, surgical outcomes benchmark satisfactorily to international standards. New Zealand's national treatment standards should set aspirational goals for gastric cancer treatment and have a clear strategy to address issues of surgical volume and national service provision.

Follow-up strategies for patients treated for non-metastatic colorectal cancer.

BACKGROUND: This is the fourth update of a Cochrane Review first published in 2002 and last updated in 2016.It is common clinical practice to follow patients with colorectal cancer for several years following their curative surgery or adjuvant therapy, or both. Despite this widespread practice, there is considerable controversy about how often patients should be seen, what tests should be performed, and whether these varying strategies have any significant impact on patient outcomes. OBJECTIVES: To assess the effect of follow-up programmes (follow-up versus no follow-up, follow-up strategies of varying intensity, and follow-up in different healthcare settings) on overall survival for patients with colorectal cancer treated with curative intent. Secondary objectives are to assess relapse-free survival, salvage surgery, interval recurrences, quality of life, and the harms and costs of surveillance and investigations. SEARCH METHODS: For this update, on 5 April 2109 we searched CENTRAL, MEDLINE, Embase, CINAHL, and Science Citation Index. We also searched reference lists of articles, and handsearched the Proceedings of the American Society for Radiation Oncology. In addition, we searched the following trials registries: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We contacted study authors. We applied no language or publication restrictions to the search strategies. SELECTION CRITERIA: We included only randomised controlled trials comparing different follow-up strategies for participants with non-metastatic colorectal cancer treated with curative intent. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently determined study eligibility, performed data extraction, and assessed risk of bias and methodological quality. We used GRADE to assess evidence quality. MAIN RESULTS: We identified 19 studies, which enrolled 13,216 participants (we included four new studies in this second update). Sixteen out of the 19 studies were eligible for quantitative synthesis. Although the studies varied in setting (general practitioner (GP)-led, nurse-led, or surgeon-led) and 'intensity' of follow-up, there was very little inconsistency in the results.Overall survival: we found intensive follow-up made little or no difference (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.80 to 1.04: I² = 18%; high-quality evidence). There were 1453 deaths among 12,528 participants in 15 studies. In absolute terms, the average effect of intensive follow-up on overall survival was 24 fewer deaths per 1000 patients, but the true effect could lie between 60 fewer to 9 more per 1000 patients.Colorectal cancer-specific survival: we found intensive follow-up probably made little or no difference (HR 0.93, 95% CI 0.81 to 1.07: I² = 0%; moderate-quality evidence). There were 925 colorectal cancer deaths among 11,771 participants enrolled in 11 studies. In absolute terms, the average effect of intensive follow-up on colorectal cancer-specific survival was 15 fewer colorectal cancer-specific survival deaths per 1000 patients, but the true effect could lie between 47 fewer to 12 more per 1000 patients.Relapse-free survival: we found intensive follow-up made little or no difference (HR 1.05, 95% CI 0.92 to 1.21; I² = 41%; high-quality evidence). There were 2254 relapses among 8047 participants enrolled in 16 studies. The average effect of intensive follow-up on relapse-free survival was 17 more relapses per 1000 patients, but the true effect could lie between 30 fewer and 66 more per 1000 patients.Salvage surgery with curative intent: this was more frequent with intensive follow-up (risk ratio (RR) 1.98, 95% CI 1.53 to 2.56; I² = 31%; high-quality evidence). There were 457 episodes of salvage surgery in 5157 participants enrolled in 13 studies. In absolute terms, the effect of intensive follow-up on salvage surgery was 60 more episodes of salvage surgery per 1000 patients, but the true effect could lie between 33 to 96 more episodes per 1000 patients.Interval (symptomatic) recurrences: these were less frequent with intensive follow-up (RR 0.59, 95% CI 0.41 to 0.86; I² = 66%; moderate-quality evidence). There were 376 interval recurrences reported in 3933 participants enrolled in seven studies. Intensive follow-up was associated with fewer interval recurrences (52 fewer per 1000 patients); the true effect is between 18 and 75 fewer per 1000 patients.Intensive follow-up probably makes little or no difference to quality of life, anxiety, or depression (reported in 7 studies; moderate-quality evidence). The data were not available in a form that allowed analysis.Intensive follow-up may increase the complications (perforation or haemorrhage) from colonoscopies (OR 7.30, 95% CI 0.75 to 70.69; 1 study, 326 participants; very low-quality evidence). Two studies reported seven colonoscopic complications in 2292 colonoscopies, three perforations and four gastrointestinal haemorrhages requiring transfusion. We could not combine the data, as they were not reported by study arm in one study.The limited data on costs suggests that the cost of more intensive follow-up may be increased in comparison with less intense follow-up (low-quality evidence). The data were not available in a form that allowed analysis. AUTHORS' CONCLUSIONS: The results of our review suggest that there is no overall survival benefit for intensifying the follow-up of patients after curative surgery for colorectal cancer. Although more participants were treated with salvage surgery with curative intent in the intensive follow-up groups, this was not associated with improved survival. Harms related to intensive follow-up and salvage therapy were not well reported.

Oesophagectomy at a New Zealand regional centre: where to now?

BACKGROUND: This study aims to define contemporary trends in characteristics, costs and management of patients diagnosed with oesophageal adenocarcinoma in New Zealand. METHODS: Clinical, pathological and management data of the 135 patients presenting with histologically proven adenocarcinoma to our institution over a 5-year period (January 2010 to December 2014) was collected. Primary analysis reviewed patient demographics, co-morbidities, treatment strategy and survival. Secondary analysis defined operative outcomes including complications, mortality rates and overall survival to December 2016. RESULTS: Thirty-eight patients underwent oesophago-gastrectomy (resection rate 28%) with curative intent following neoadjuvant chemotherapy with Clavien-Dindo ≥3 complications in 17 patients (46%). Actuarial survivals from surgery at 1, 3 and 5 years were (79, 55 and 50%), with 19 patients (54%) alive and disease free at a median follow-up of 26.5 months (range 1-82 months). Overall, this represented one sixth of the national volume of oesophagectomy. Ninety-seven patients were managed non-surgically due to metastatic or advanced local disease (n = 64), co-morbid status (n = 27), patients choice (n = 2) and unknown (n = 4). Median survival from diagnosis in non-resected patients was 9 months (range 1-40 months). CONCLUSION: Oesophagectomy remains a challenging procedure for any institution, although good results can be achieved. Foci for referral are emerging in New Zealand for the surgical management of oesophageal cancer.

From scratch: developing a hepatic resection service for metastatic colorectal cancer.

BACKGROUND: Waitemata District Health Board has New Zealand's largest catchment and busiest colorectal unit. The upper gastrointestinal unit was established in 2005, in part to provide a hepatic resection service for patients with colorectal carcinoma metastatic to the liver. The aim of this investigation was to report on quality indicators for the hepatic resection of colorectal carcinoma in the development of a regional resection service. METHODS: Prospectively collected data on patients undergoing hepatic resection for colorectal carcinoma between 2005 and 2014 was reviewed and correlated with costing data and national hepatic resection rates. RESULTS: A total of 123 patients underwent 138 hepatic resections for metastatic colorectal cancer with a median hospital stay of 8 days (range 4-37 days), a zero 30-day mortality and a median cost of NZ$21 374 for minor hepatectomy and NZ$43 133 for major hepatectomy. Actuarial 5-year disease-free survival was 44%, with 28 patients alive and disease free at 5 years post-resection. Median overall survival was not reached. Review of national hepatic resection rates indicate that Waitemata District Health Board performs one sixth of all hepatic resections in New Zealand and that this treatment modality may be underutilized in the management of patients with metastatic colorectal cancer. CONCLUSION: A regional hepatic resection centre for colorectal metastases can be established in areas of population need and can provide a high-quality, cost-effective service.

The volume, cost and outcomes of pancreatic resection in a regional centre in New Zealand.

BACKGROUND: The frequency, costs and outcome of pancreatic resection (both pancreaticoduodenectomy and distal pancreatectomy) were reviewed in our own institution and correlated with regional population growth as well as national resection rates and locations. METHODS: Demographic, pathological and outcome data on pancreaticoduodenectomy and distal pancreatectomy were obtained from a prospectively maintained database for the years 2005-2009 and 2010-2014. During this period, the catchment population grew from 460 000 to 567 000. Costing information was obtained from the hospital-independent costing and coding committee, and the locations and rates of pancreatic resection were obtained by interrogating the national minimum dataset. RESULTS: A total of 41 pancreatectomies (29 pancreaticoduodenectomy, 12 distal pancreatectomy) were performed between 2005 and 2009, increasing to 84 pancreatectomies (55 pancreaticoduodenectomies, 27 distal pancreatectomies and two total pancreatectomies) between 2010 and 2014. This constituted one sixth of the national volume of pancreatic resections. There was no difference in patient demographics or indications for resection between the two time periods; however, portal vein resection was used more frequently in the second period. Margin positivity rate decreased (7 of 41 versus 8 of 84) and lymph node harvest increased (median 8 nodes versus median 15 nodes) between the two time periods. Overall 30-day mortality was 1.6%. CONCLUSION: In New Zealand, regional rates of pancreatic resection reflect regional population demands, and institutional growth is driven by local population requirements. Institutional growth can be achieved with the maintenance of internationally accepted outcomes and quality indicators.